surgery / insurance process begins....

[David]

While we are on this topic, I guess I should ask what the general process is and what to expect.

My girlfriend, who does do some insurance work for a doctor's office says that the initial step is predetermination, and is basically whether or not the insurance company thinks they might cover the cost. I say might, because she also says that the insurance company could deny any or all of the claim, *after* surgery. Is this correct or incorrect?

So, presuming the above is valid:

If the insurance company denies predetermination, what is my next step?

If the insurance company approves predetermination, but later (after the surgery) denies some or all of my claim, what happens then?

Basically, I am concerned that the insurance company might approve me for surgery, I would have surgery, and then I would be stuck with a large $ to pay.

Am I making any sense at all?

Thanks.

David "he who works for the evil Qwest"

[NCFUSED]

David,

I work for a Large Bank....Currently hosting Tiger Woods in this weeks Golf Tourney...

Denial grounds were "Experimental, Investigational, or Unproven service"

What kills me is that my Comapny also offers Aetna for North East Employees, not in the Carolinas though, only UHC, Cigna and BCBS.....

I started the whole process back in August last year, after years of seeing a Chiropractor for pain, 1st the Insurance Co, said I needed to comply with 6 months of documented un-invasive procedures such as PT, lumbar injections, drugs.
In late Dec/04. I got my 1st denial for Surgery in Jan/05, 2nd denial in late Feb. and the last a few days ago....

also, if precert is denied, they will ask you to send an appeal to the UHC appeals center in Utah, then they kill another 30+ days, and deny
again, then if your Company is self funded, you have to appeal to them, count on another 30+ days.
If it is not self funded, you can appeal to your state's insurance commission. So over 6 months later, Im back to square one...fusion.


I have a good friend here that is a Police Officer who had L5-S1 fused a few years ago, he hardly notices it at that level. Eventually I will probably end up with problems at the levels above, my doctor is hopeful ADR will be better accepted by then.... he is 1/15 so far getting insurance approvals..... The 1 was a WC case...


Hopefully you will do better than I did....

[David]

Thanks for the info. All I can do is try and see what happens.

I refuse to be fused, so if UHC won't cover me, then I will probably be scheduling a trip to das Vaterland.

David